Can axillary lymph node dissection be omitted in patients with breast cancer and positive sentinel nodes?

Sentinel lymph node biopsy has evolved as the surgical procedure of choice for women with clinically negative axillae, as part of an effort to move toward the less invasive surgical management of breast cancer. Axillary lymph node dissection remains the standard of care for patients with a positive axillary node and was previously performed on all patients with breast cancer prior to the implementation of the sentinel lymph node biopsy. There is, however, controversy regarding whether or not all patients with a positive sentinel lymph node need to undergo completion axillary dissection for either prognostic or therapeutic purposes. This article reviews the literature related to this controversial and evolving topic.     

Is axillary lymph node dissection always necessary in breast cancer patients with a positive sentinel node?

Axillary lymph node dissection (ALND) is recommended for patients with breast cancer metastasis to a sentinel lymph node (SLN). However in 40-70% of cases, the SLN may be the only area of metastasis in the dissected axillary contents. In patients with a positive SLN, independently predictive factors for non-SLN metastasis include size of the primary tumor, the size of the SLN metastases, extracapsular extension, and the proportion of positive SLN's among all identified SLNs. Some authors have developed scores and nomograms to estimate a patient's risk for non-SLN metastases. These scores and nomograms should be applied prospectively to a large numper of SLN positive patients who thereafter undergo completion ALND. It is necessary to verify the predictive validity of these scores before we recommend the abandonment of ALND in patients with a very low likelihood of non-SLN metastasis. In this article we review the various predictive factors of non-SLN involvement and the scores or nomograms which have been developed to predict the likelihood of a positive ALND after a positive SLN biopsy.     

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.     

Is extended lymph node dissection necessary for gastric cancer in elderly patients?

OBJECTIVE: To compare the outcome after limited and extended gastric resections to find out whether extended lymph node dissection is indicated for gastric cancer in elderly patients. DESIGN: Retrospective study. SETTING: University hospital, Japan. SUBJECTS: 182 patients over 75 years of age with gastric cancer who had gastric resections from 1980 to 1995. INTERVENTIONS: 161 patients had limited lymph node dissection (limited group) and 21 had extended lymph node dissection (extended group). MAIN OUTCOME MEASURES: Histopathological features, morbidity, mortality, and long-term survival. RESULTS: Postoperative morbidity was 27% (n = 44) in the limited group and 57% (n = 12) in the extended group, and postoperative mortality was 1% (n = 2) in the limited group and 10% (n = 2) in the extended group; these differences are significant (p = 0.005 and p = 0.002). The 5-year survival did not differ significantly between the two groups. Only the T classification and presence of lymph node metastases had a significant influence on the outcome of gastric cancer in elderly patients. CONCLUSIONS: The presence of lymph node metastases is a critical factor in the prognosis of gastric cancer, and extended lymph node dissection has therefore been recommended. However, extended lymph node dissection in elderly patients did not influence the 5-year survival; in addition, the mortality and morbidity in the extended group were higher than in the limited group. Extended lymph node dissection is therefore usually not indicated for gastric cancer in elderly patients.     

High body mass index predicts multiple prostate cancer lymph node metastases after radical prostatectomy and extended pelvic lymph node dissection

Our aim is to evaluate the association between body mass index(BMI)and preoperative total testosterone(TT)levels with the risk of single and multiple metastatic lymph node invasion(LNI)in prostate cancer patients undergoing radical prostatectomy and extended pelvic lymph node dissection.Preoperative BMI,basal levels of TT,and prostate-specific antigen(PSA)were evaluated in 361 consecutive patients undergoing radical prostatectomy with extended pelvic lymph node dissection between 2014 and 2017・Patients were grouped into either nonmetastatic,one,or more than one metastatic lymph node invasion groups.The association among clinical factors and LNI was evaluated.LNI was detected in 52(14.4%)patients:28(7.8%)cases had one metastatic node and 24(6.6%)had more than one metastatic node.In the overall study population,BMI correlated inversely with TT(r=-0.256;P<0.0001).In patients without metastases,BMI inversely correlated with TT(r=-0.282;P<0.0001).In patients with metastasis,this correlation was lost.In the overall study population,BMI(odds ratio[OR]=1.268;P=0.005)was the only in dependent clinical factor associated with the risk of multiple metastatic LNI compared to cases with one metastatic node.In the nonmetastatic group,TT was lower in patients with BMI>28 kg m^2(P<0.0001).In patients with any LNI,this association was lost(P=0.232).The median number of positive nodes was higher in patients with BMI>28 kg m^2(P-0.048).In our study,overweight and obese patients had a higher risk of harboring multiple prostate cancer lymph node metastases and lower TT levels when compared to patients with normal BMI.     

Can radiotherapy replace axillary dissection for patients with positive sentinel nodes?

The substitution of sentinel node biopsy for axillary dissection for patients with early-stage breast cancer has reduced the morbidity of pathologic axillary nodal staging substantially. However, this has resulted in substantial controversy about how to manage patients with positive sentinel nodes. Radiation therapy has been used for many years instead of or in addition to axillary sampling or axillary dissection. This article will examine parts of this experience relevant to the treatment of patients with positive sentinel node biopsy, the limited data on outcome of patients with a positive sentinel node biopsy who do not undergo completion dissection, and the toxicities of axillary irradiation. Finally, I suggest an overall approach to the management of patients with a positive sentinel node biopsy.     

Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection?

Introduction

Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity.

Does pelvic lymph node dissection improve the biochemical relapse-free survival in low-risk prostate cancer patients treated by laparoscopic radical prostatectomy?

Abstract Background and Purpose: The roles and criteria for pelvic lymph node dissection (PLND) are not fully evaluated in patients with low-risk prostate cancer who are treated by laparoscopic radical prostatectomy (LRP). In this study, the outcome of PLND was assessed in terms of the biochemical relapse-free survival rates of low-risk prostate cancer patients who had undergone LRP. Patients and Methods: Included were 286 consecutive patients who were treated with LRP without previous endocrine therapy between 2002 and 2006 at our institution. Failure rates for LRP were compared in 139 patients with low-risk prostate cancer between those who underwent PLND (n=85) and those who did not (n=54). Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. Results: The mean number of retrieved lymph nodes was 5.4±0.4 (range 2-22). The 5- and 7-year biochemical relapse-free survival rates were 90.1% and 88.3% in patients with PLND, and 82.4% and 82.4% in those without PLND (P=0.278), respectively (median follow-up 69.4 mos). None of the 85 patients undergoing PLND had positive lymph nodes. Only one patient had symptomatic lymphocele, and he was treated as an inpatient. The average time needed for PLND was 16 minutes, which corresponded to 7% of the entire operative time. Conclusion: These results indicate that the dissection of pelvic lymph nodes is not related to biochemical relapse-free survival. The omission of PLND in patients with low-risk prostate cancer not only does not adversely affect biochemical relapse-free survival, but might decrease the incidence of complication and operative time of LRP.     

Do bone marrow micrometastases correlate with sentinel lymph node metastases in breast cancer patients?

BACKGROUND: Sentinel lymph node biopsies (SLNB) are used to detect axillary metastases as an important prognostic indicator for breast cancer patients. Bone marrow micrometastases (BMM) have also been shown to predict prognosis. This study examines whether SLNB and BMM are associated. STUDY DESIGN: A retrospective analysis was performed on 124 stages I to III breast cancer patients treated with mastectomy or lumpectomy, SLNB, and bone marrow aspiration between 1997 and 2003. SLNB were examined for the presence of metastases by hematoxylin and eosin (H&E) stains and also by immunohistochemistry (IHC) for lymph nodes negative by H&E. The kappa statistic was used to evaluate the association (agreement) between SLNB and BMM. RESULTS: In this study population, 36 patients (29%) had micrometastases detected in their bone marrow, and 51 patients (41%) had positive sentinel lymph nodes. Of the patients with positive BMM (n = 36), 53% (19 of 36) had positive SLNB (14 of 19 by H&E and 5 of 19 by IHC). In patients with negative BMM (n = 88), 36% (32 of 88) had a positive SLNB (27 of 32 by H&E and 5 of 32 by IHC). The kappa statistic and associated 95% confidence interval indicated poor agreement between SLNB and BMM (kappa = 0.15; 95% CI = -0.03, 0.32). CONCLUSIONS: There was poor agreement between axillary metastases and micrometastases detected in the bone marrow. This study suggests that BMM and axillary metastases are not concordant findings in most patients.     

Is it necessary to do staging pelvic lymph node dissection for T1c prostate cancer?

The necessity of pelvic lymph node dissection has been questioned in recent years as a result of improved pre-treatment staging based on clinical and pathologic factors. Accurate evaluation of nodal status allows rational selection of therapy and improved outcomes. Nevertheless, lymph node dissection may play a role even in patients with low stage disease (clinical T1c) despite an overall low risk for metastases. Herein we discuss recent advances in the evaluation of lymph nodes in stage T1c prostate cancer with respect to accurate prediction, radiologic imaging, molecular characterization, and operative considerations.     

Is sentinel lymph node biopsy more accurate than axillary dissection for staging nodal involvement in breast cancer patients?

Today evaluation of axillary involvement can be routinely performed with the technique of sentinel lymph node biopsy (SLNB). One of the greatest advantages of SLNB is the nearly total absence of local postoperative complications. It is important to understand whether SLNB is better than axillary lymph-node dissection (ALND) for staging axillary nodal involvement. The aim of the study was to evaluate the axillary staging accuracy comparing three different methods: axillary dissection, sentinel node biopsy with the traditional 4-6 sections and sentinel node biopsy with complete analysis of the lymph node. 527 consecutive patients (525 females and 2 males) with invasive breast cancer < or = 3 cm and clinically negative axillary nodes were divided into 3 different groups: group A treated with axillary dissection, group B treated with sentinel nodal biopsy analysed with 4-6 sections, and group C treated with sentinel node biopsy with analysis of the entire node. All patients underwent a quadrantectomy to treat the tumor. Group differences and statistical significance were assessed by ANOVA. The percentages of N+ in group A and group B were 25.80% and 28% respectively, while in the third group it rose to 45%, or almost half the patients. The differences among the three groups were statistically significant (p = 0.02). From our analysis of the data it emerges that axillary dissection and sentinel node biopsy with analysis of 4-6 sections have the same accuracy in staging the nodal status of the axilla; analysis of the entire sentinel lymph node revealed an increased number of patients with axillary nodal involvement, proving more powerful in predicting nodal stage. SLNB with complete examination of the SLN removed can be considered the best method for axillary staging in breast cancer patients with clinical negative nodes. In our study, the percentage of metastases encountered after complete examination of SLN was 45% compared to the accuracy of axillary dissection that was only 25.8%. Moreover, this approach avoids the useless axillary cleaning in about 55-60% of cases, decreasing postoperative morbidity and mortality.     

Does the presence of sentinel lymph node macrometastases in breast cancer patients require axillary lymph node dissection?—Single‐center analysis

According to the current guidelines on treatment of breast cancer patients, identification of metastases in the sentinel lymph node (SLN (+)) is not an absolute indication for necessary axillary lymph node dissection (ALND). In our study, we present long‐term outcomes of treatment among SLN(+) patients referred for conservative treatment, for example, no further ALND. A total of 3145 breast cancer patients subjected to sentinel lymph node biopsy (SLNB) between November 2008 and June 2015. SLN metastases were identified in 719 patients (22.9%). Locoregional recurrences and distant metastases as endpoints were distinquished. The mean follow‐up time for patients after ALND was 36.2 months (6‐74 months); 18.8 months (6‐38 months) for patients with SLN macrometastases without ALND; and 34.0 months (6‐74 months) for patients with micrometastases. Adjuvant ALND was performed in 626 of SLN(+) patients. Conservative treatment was applied in the remaining 93 cases. Among SLN(+) patients without adjuvant ALND, there was one case of recurrence (1.07%). In the group of patients without SLN, metastases recurrence was noted in 32 patients (1.32%). Among SLN(+) patients diagnosed with macrometastases, recurrence concerned 2.01% of analyzed cases (all subjected to ALND). Lack of radical surgical treatment in SLN(+) breast cancer patients did not lead to worsening long‐term outcomes. In the occurrence of macrometastases to the sentinel lymph node, abandoning completion axillary lymph node dissection might be a reasonable option. However, it would require continuation of current research, preferably involving a clinical trial.     

Is routine primary retroperitoneal lymph node dissection still justified in patients with low stage non-seminomatous testicular cancer?

We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non-seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage IIa (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM+) and 121 had normal tumour markers (CSIM-). Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM-, in 19 of 33 patients with CSIIM+ and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half-life were predictive factors for PSII. These 2 factors enabled a group of non-seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases. Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post-operative complications. In addition, "dry ejaculation" was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients). The comparative cost to the health service during the first year of follow-up was estimated for low risk non-seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable. It was concluded that a surveillance policy should be followed in low risk non-seminoma CSI patients provided that frequent follow-up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve-sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.     

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

PURPOSE: Generally lymph node dissection is only considered a staging procedure for prostate cancer. Therefore, the need for meticulous lymph node dissection is often questioned and only sampling is suggested. We performed a prospective study to identify the pattern of lymph node metastasis in prostate cancer and determine how extensive lymph node dissection must be not to under stage cases. MATERIALS AND METHODS: All patients with clinically organ confined prostate cancer, no prior hormonal treatment, negative preoperative staging computerized tomography and bone scan, who underwent radical prostatectomy between 1989 and 1999, were evaluated prospectively as to the number and location of lymph node metastasis. A meticulous lymph node dissection was performed along the external iliac vein, obturator nerve and internal iliac (hypogastric) vessels. Nodes from each location and side were submitted separately for histological evaluation. RESULTS: In 365 patients with a median serum prostate specific antigen of 11.9 ng./ml. (range 0.4 to 172) the median number of nodes removed was 21 (range 6 to 50). Lymph nodes were positive in 88 (24%) patients and the median number of positive nodes was 2 (range 1 to 19). Internal iliac lymph nodes were positive in 51 (58%) of the 88 patients, including 34 with additional positive lymph nodes along the external iliac vein and/or obturator nerve. Internal iliac lymph nodes alone were positive in 17 (19%) of 88 patients. CONCLUSIONS: There were significant numbers of lymph node metastases at all 3 different areas of lymphadenectomy. Positive lymph nodes were found along the internal iliac artery in more than half (58%) of the patients and exclusively in 19%. Therefore, we consider lymph node dissection along the internal iliac (hypogastric) vessels essential for representative staging. Without this dissection a fifth of node positive cases would have been under staged and diseased nodes would have remained in more than half of the cases.